published as: shonin, e., van gordon w., & griffiths m.d....
TRANSCRIPT
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Published as: Shonin, E., Van Gordon W., & Griffiths M.D. (2014). The emerging
role of Buddhism in clinical psychology: Towards effective integration. Psychology of
Religion and Spirituality, 6, 123-137.
Abstract
Research into the clinical utility of Buddhist-derived interventions (BDIs) has increased
greatly over the last decade. While clinical interest has predominantly focussed on
mindfulness meditation, there has also been an increase in the scientific investigation of
interventions that integrate other Buddhist principles such as compassion, loving kindness,
and ‘non-self’. However, due to the rapidity at which Buddhism has been assimilated into the
mental health setting, issues relating to the misapplication of Buddhist terms and practices
have sometimes arisen. Indeed, hitherto, there has been no unified system for the effective
clinical operationalization of Buddhist principles. Therefore, this paper aims to establish
robust foundations for the ongoing clinical implementation of Buddhist principles by
providing: (i) succinct and accurate interpretations of Buddhist terms and principles that have
become embedded into the clinical practice literature, (ii) an overview of current directions in
the clinical operationalization of BDIs, and (iii) an assessment of BDI clinical integration
issues. It is concluded that BDIs may be effective treatments for a variety of
psychopathologies including mood-spectrum disorders, substance-use disorders, and
schizophrenia. However, further research and clinical evaluation is required to strengthen the
evidence-base for existent interventions and for establishing new treatment applications.
More importantly, there is a need for greater dialogue between Buddhist teachers and mental
health clinicians and researchers in order to safeguard the ethical values, efficacy, and
credibility of BDIs.
Key Words: Mindfulness, Meditation, Compassion, Loving Kindness, Buddhism, Clinical
Interventions
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The Emerging Role of Buddhism in Clinical Psychology:
Towards Effective Integration
Introduction
“Wonderful, indeed, it is to tame the mind, so difficult to tame, ever swift, and seizing
whatever it desires. A tamed mind brings happiness”
- Buddha (as cited in Buddharakkhita, 1966)
According to the Mental Health Foundation (MHF; 2010), one in four British adults practice
meditation and 50% would be interested in learning to meditate as a means of coping with
stress and improving their health. Furthermore, approximately 75% of general practitioners in
the United Kingdom believe that meditation is beneficial for people with mental health
problems (MHF, 2010). Comparatively lower figures are reported for America where over 20
million people (~ 6.5% of the population) practice meditation (Elias, 2009). The Buddhist-
derived practice of mindfulness, in the form of Mindfulness-Based Cognitive Therapy (MBCT;
Segal, Williams, & Teesdale, 2002), is now advocated by both the National Institute for Health
and Clinical Excellence (2010) and the American Psychiatry Association (2009) for the
treatment of specific forms of depression. Indeed in 2012, almost 500 scientific papers
concerning mindfulness were published which compares with just 50 papers concerning
mindfulness published ten years prior to this in 2002. Likewise and in the last five years, other
Buddhist principles such as compassion, loving kindness, and ‘non-self’ have been integrated
into a battery of purposefully-developed psychopathology interventions (e.g., Gilbert, 2009;
Johnson et al., 2011, Pace et al., 2012; Shonin, Van Gordon, & Griffiths, 2013a).
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Interest into the clinical utility of Buddhist-derived interventions (BDIs) is growing. Potential
treatment applications for BDIs span almost the entire spectrum of psychological disorders
including (for example) mood disorders (Hofmann, Sawyer, Witt, & Oh, 2010), anxiety
disorders (Vøllestad, Nielson, & Nielson, 2011), substance use disorders (Witkiewitz,
Bowen, Douglas, & Hsu, 2013), personality disorders (Soler et al., 2012), and schizophrenia-
spectrum disorders (Johnson et al., 2011). BDIs also effectuate improvements in
psychological wellbeing, cognitive function, and emotion regulation capacity in sub-clinical
and healthy-adult populations (e.g., Chiesa, Calati, & Serretti, 2011; Desbordes et al., 2012;
Eberth, & Sedlmeier, 2012; Van Gordon, Shonin, Sumich, Sundin, & Griffiths, 2013).
The assimilation of Buddhist practices by allied health disciplines is likely to have been
influenced by factors such as: (i) increased rates of transnational migration resulting in
greater cultural and ethnic diversity amongst service-users (Kelly, 2008), (ii) the need to
develop culturally syntonic treatments for Asian Americans and Asian Europeans (Hall,
Hong, Zane, & Meyer, 2011), (iii) Buddhism’s orientation as more of a philosophical and
practice-based system relative to some religions where a greater emphasis is placed on
worship and dogma (Shonin, Van Gordon & Griffiths, 2013b), (iv) similarities between
Buddhism and established therapeutic modes such as Cognitive Behavior Therapy (CBT) in
terms of their construal of the relationship between thoughts, feelings, and behavior (Segall,
2003), (v) the need for novel interventions that can augment the effectiveness of
psychopathology treatments where relapse rates in modes such as CBT can be as high as 60-
75% (e.g., Hodgins, Currie, el-Guebaly, & Diskin, 2007; Emslie, Mayes, Laptook, & Batt,
2003), (vi) the growth in research examining the effects of Buddhist meditation on brain
neurophysiology (e.g., Cahn, Delorme, & Polich, 2010), (vii) the wider scientific dialogue
concerned with the evidence-based applications of specific forms of spiritual practice for
improved psychological health (Lindberg, 2005), (viii) the international recognition and
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acclaim of prominent Buddhist leaders such as Nobel Peace Prize laureate H.H. XIV Dalai
Lama and Nobel Peace Prize nominee Thich Nhat Hanh, (ix) increases in the number of
seminal Buddhist works translated into English language (and improvements in the
translation quality thereof), and (x) the recent (i.e., during the last 30-40 years) founding in
the West of practice centres representative of the majority of the world’s Buddhist traditions.
The manner in which Buddhism (when considered as a single entity) has been made available
to the interested Westerner has been relatively unstructured. In conjunction with the rapidity at
which Buddhist principles have been integrated into clinical interventions, it is therefore
unsurprising that a degree of confusion has arisen within the clinical and psychological
literature regarding the accurate meanings of Buddhist terms (Rosch, 2007). Dorjee (2010)
provided an example of such confusion based on the term ‘insight’ which has been used within
the psychological literature (e.g., Brown, Ryan, & Creswell, 2007) to refer to an increase in
perceptual distance (e.g., from thoughts and feelings) that often follows mindfulness practice.
However, within Buddhism, the term ‘insight’ is generally used in the context of transcendent
intuitive leaps of realization into the very nature of reality itself. A further example relates to
the practice of ‘vipassana meditation’ which is generally described in the healthcare literature
as being synonymous with mindfulness meditation. Although there are some similarities
between these two forms of meditation, according to traditional Buddhist perspectives (and as
will be explicated below), they represent two distinct meditative modes (Van Gordon et al.,
2013). In fact, even the term ‘mindfulness’ takes on a different meaning in the Buddhist
literature vis-à-vis its conceptualization by Western psychologists (Kang & Whittingham,
2010).
For techniques such as mindfulness, there have been various attempts to reconcile some of
these terminological issues. Nevertheless, to date, there remains a lack of consensus amongst
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psychologists as to what defines the mindfulness construct (Chiesa, 2012). Furthermore, since
scientific debate regarding the salutary health effects of Buddhist practice has predominantly
focussed on mindfulness meditation, terminological and operational issues relating other
clinically-employed Buddhist principles have been entirely over-looked. Moreover, proposed
schemas for interpreting or operationalizing Buddhist concepts invariably fail to consider the
cooperating or mechanistic role of other Buddhist principles (Van Gordon et al., 2013). Indeed,
hitherto, there is currently no unified and structured system for the effective interpretation,
classification, and operationalization of Buddhist terms, principles, and practices within clinical
settings.
Consequently, the purpose of the current paper is to propose such a system and establish robust
foundations for the on-going clinical implementation of Buddhist principles and practices.
More specifically, this paper aims to provide: (i) succinct clinician-relevant interpretations of
key Buddhist terms and principles that are truer and more closely aligned with their intended
meaning (limited to those Buddhist terms that have become embedded or utilized within the
clinical literature), (ii) an outline and discussion of current directions concerning the full-
spectrum of Buddhist principles currently employed in clinical interventions (however, this
paper is not intended as a systematic literature review – recent systematic reviews are
highlighted where appropriate throughout the paper), and (iii) an assessment of issues that arise
from the continued operationalization and roll-out of BDIs within clinical and psychological
settings.
Contextual Background
Buddhism originated approximately 2,500 years ago and is based on the teachings of
Siddartha Gautama (later becoming known as Shakyamuni Buddha) who taught throughout
India. Although Buddhism takes on many different forms, one method of classification is to
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assign each particular tradition of Buddhism to one of three overriding vehicles (Sanskrit and
Pali: yanas): (i) Theravada Buddhismi (sometimes subsumed under the title of Shravakayana
– ‘the hearer vehicle’), (ii) Mahayana Buddhism (‘the great vehicle’), and (iii) Vajrayana
Buddhism (‘the diamond vehicle’). Theravada Buddhism is the longest-enduring school of
Buddhismii and is prevalent throughout South East Asian countries such as Thailand, Sri
Lanka, and Burma. Mahayana Buddhism is believed to have originated around the turn of the
first century AD and is prevalent throughout East Asia (e.g., Japan, Taiwan, Korea, and
Vietnam). Vajrayana Buddhism is generally considered to have originated in the seventh
century and is associated with Himalayan plateau countries such as Tibet, Bhutan, Nepal, and
Mongolia (and to a lesser extent Japan). All three vehicles are now practiced in the West.
The defining characteristics of each Buddhist vehicle might be concisely summarized as
follows: (i) greater adherence in Theravada Buddhism to the ‘original word’ of the historical
Buddha, (ii) greater emphasis in Mahayana Buddhism on compassionate activity and the
‘non-dual’ or ‘empty’ nature of phenomena, and (iii) greater significance in Vajrayana
Buddhism placed on ‘sacred outlook’, the bond with the spiritual guide or ‘guru’, and on
more esoteric practices intended to effectuate a realization of the ‘nature of Mind’.
Notwithstanding these variances, the underlying Buddhist rudiments of wisdom, meditation,
and ethical awareness reflect the root principles of each Buddhist vehicle. The three
principles of wisdom, meditation, and ethical awareness are collectively known as ‘the three
trainings’ (Sanskrit: trishiksha; Pali: tisso-sikkha) and encompass the entire spectrum of
Buddhist practices. Therefore, section headings of (i) ‘Wisdom’, (ii) ‘Meditation’, and (iii)
‘Ethical Awareness’ are used to conceptually stratify the current paper (and each of these
three sections is further divided into subsections of (i) Meanings, (ii) Current Directions, and
(iii) Clinical Integration Issues. The classification of Buddhist principles and derivative
interventions according to categories of Wisdom, Meditation, and Ethical Awareness is also
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proposed as a system suitable for adoption by Western psychology as part of a unified
operational approach.
Method of Interpretation and Didacticism
In our usage and descriptions of Buddhist terms, we have endeavoured to impart some
measure of their ‘experiential meaning’ while adhering to widely-accepted interpretations and
didactic modes (the first two authors have been Buddhist monks for approximately 30 and 10
years respectively, and all of the authors are research psychologists that have a clinical focus
to their research outlook). Although the views of teachers from a wide range of living
Buddhist traditions are reflected, we have frequently favoured interpretations as promulgated
by the current Dalai Lama. Our reasons for so doing are because the Dalai Lama, although an
obvious representative of the Tibetan Buddhist approach (and in particular the Gelug tradition
of Tibetan Buddhism), is regarded by many living Buddhist traditions (some contemporary
Chinese Buddhist traditions being notable exceptions) as somebody who embodies an
authentic ‘worldview’ of the Buddhist teachings. This fits well with the authors’ own view
that while it is advisable for clinicians and researchers to be aware that there exist
multifarious interpretations of Buddhist terms, it is probably more pragmatic and helpful if
they (and perhaps Buddhist adherents more generally) adopt a unifying rather than divisive
approach to the Buddhist teachings. Furthermore, the Dalai Lama (as with many
Mahayana/Vajrayana Buddhist teachers) accepts the full authenticity of, and uses as a basis,
the teachings of the earlier cycle of Buddhist transmission (e.g., the Theravada tradition).
Interpretations by the Dalai Lama were also favoured because he is frequently cited in the
clinical and psychological literature and his teachings are readily accessible to a Western
readership.
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Consistent with the stated aims of the paper, explanations of Buddhist terms are restricted to
only those that have become embedded or utilized within the clinical and psychological
literature. The present paper is not intended to be an answer for all unresolved Buddhist
debates regarding terminological propriety, nor a compendium providing ‘absolute’
definitions of Buddhist terms (such a paper has never been written in the entire 2,500 history
of Buddhism). Indeed, each tradition of Buddhism (and arguably each teacher within a given
tradition) has their own experiential understanding of a given aspect of Buddhist practice. In
fact, each individual term introduced in this paper could easily become the subject of several
papers in their own right. Thus, although not without its limitations, the method employed for
elucidating Buddhist terms and principles is deemed to be apt given the scope of the paper as
well as its intended readership (i.e., researchers, academicians, and clinicians interested in the
psychological and clinical applications of Buddhist practice).
Wisdom: Redefining Self and Reality
Meanings
Buddhist wisdom-related terms or concepts frequently referred to in the mental health
literature include ‘wisdom’, ‘deluded’, ‘non-self’, ‘attachment’, ‘impermanence’,
‘interconnectedness’, ‘emptiness’, and ‘original nature’.
Wisdom: In order to appreciate some of the nuances of the Buddhist construal of wisdom (and
of other aspects of Buddhist thought), Shonin et al (2013b) recently proposed ‘ontological
addiction’ as a new category of addiction (i.e., in addition to substance addiction and
behavioral addiction). Ontological addiction is defined as “the unwillingness to relinquish an
erroneous and deep-routed belief in an inherently existing ‘self’ or ‘I’ as well as the
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‘impaired functionality’ that arises from such a belief” (Shonin et al., 2013b, p.64). The
ontological addiction formulation is a means of operationalizing within Western clinical
domains the Buddhist view that suffering, including the entire spectrum of distressing
emotions and psychopathologic states, results from adhering to a false view of self and
reality. Therefore, within Buddhism, ‘wisdom’ refers to the gradualiii development of insight
that allows and facilitates an individual to undergo recovery from ontological addiction by
reconstructing their view of self and reality. Thus, the Buddhist notion of wisdom differs
from the Western psychological depiction where wisdom is generally measured against
parameters of knowledge, adaptive psychological functioning, and socio-environmental
mastery (Baltes & Staudinger, 2000).
Deluded: The term ‘deluded’ (or delusional) is frequently used within Buddhism, yet it takes
on a much broader meaning when compared to its use in clinical psychology. The concept of
‘mindlessness’ provides a notable example for understanding this difference and for
illuminating a key Buddhist premise. Mindlessness (as opposed to mindfulness) refers to a
lack of present moment awareness whereby the mind is preoccupied with future (and
therefore fantasized) conjectures or past (and therefore bygone) occurrences. In this regard,
interesting similarities can be drawn between mindlessness and certain forms of
hallucination. Insofar as hallucination refers to ‘the perceiving of that which is not’, we
would argue that mindlessness might be designated as a form of ‘inverted hallucination’, due
to it being the ‘non-perceiving of that which is’. With the exception of individuals who have
progressed along the ‘spiritual stream’, Buddhism assigns mindlessness as the default
disposition of the population en masse. Thus, the majority of individuals considered
‘mentally healthy’ and psychosocially adaptive by Western conventions (e.g., as defined by
the World Health Organization) would still be considered to be immersed in ‘delusion’
according to Buddhist philosophy (Suzuki, 1983).
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Non-self: There are numerous formulations of ‘the self’ in Western psychology and many of
these are constructed on the basis of their being a definite ‘I’ entity (see Sedikides & Spencer,
2007). In such formulations, the self is often represented as being separate from the world
around it such that the possibility of ‘self in other’ and ‘other in self’ is often overlooked
(Sampson, 1998). Furthermore, even in the psychological study of human personality, social
relationships, and cognitive and behavioral processes where a self is not explicitly posited,
there is an implicit acceptance of an inherently existing ‘I’ (Chan, 2008). Within Buddhism,
the term ‘non-self’ refers to the realization that the ‘self’ or the ‘I’ is absent of intrinsic
existence (Dalai Lama, 2005). As explained in the Shalistamba sutra (Reat, 1993), Buddhism
asserts that the individual comprises five aggregates [(i) form, (ii) feelings, (iii) perceptions,
(iv) mental formations, and (v) consciousness; Sanskrit: skandhas; Pali: khandhas] and that
an inherently existing self may not be found within the aggregates whether in singular or in
sum. For example, the form aggregate (e.g., the human body; Sanskrit and Pali: rupa),
consists of (amongst other things) skin, bones, teeth, hair, organs, and tissue. Buddhist
teachings assert that the body manifests only in dependence upon its constituent parts and that
the ‘selfness’ of body may not be found.
Non-attachment: In many respects, the concept of non-self is intrinsically interwoven with
the concept of non-attachment. The Dalai Lama (2001) asserts that attachment is an
undesirable quality that leads to the reification of the ego-self. Afflictive mental states arise
due to the imputed ‘self’ incessantly craving after objects it deems to be attractive or
harboring aversion towards objects deemed to be unattractive (Chah, 2011). Thus, the present
authors would argue that the Buddhist notion of attachment could be defined as ‘the over-
allocation of cognitive and emotional resources towards a particular object, construct, or idea
to the extent that the object is assigned an attractive quality that is unrealistic and that exceeds
its intrinsic worth’. The Buddhist non-attachment construct is not discordant with the
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Western psychological construal of attachment that, in the context of certain relationships, is
generally considered to exert a protective influence over psychopathology (Sahdra, Shaver, &
Brown, 2010). The reason for this is because Buddhism does not assert that the relationship
stakeholders of psychosocially and developmentally adaptive relationships (e.g., between
caregiver and child) assign an attractive quality to those relationships ‘that is unrealistic and
that exceeds their intrinsic worth’. An example of the Buddhist portrayal of ‘attachment’ (i.e.,
as a maladaptive behavioral strategy) would be a relationship between husband and wife
where one or both parties’ relationship behavior is controlling, possessive, and/or highly
conditional.
Impermanence: Within Buddhism, ‘impermanence’ refers to the fact that all phenomena are
transient occurrences and are subject to decay and dissolution (Sogyal, 1998). Along with
‘suffering’ and ‘non-self’, impermanence constitutes one of the three Buddhist ‘seals’iv or
‘marks’ of existence (for an introduction to basic Buddhist tenets and teachings, see Bodhi,
1994; Dalai Lama, 2005; Nhat Hanh, 1999). The universal law of ‘impermanence’ applies as
much to psychological phenomena such as thoughts, feelings, and perceptions, as it does to
material phenomena both animate (e.g., the birth, life, and death of sentient beings) and
inanimate. Cultivating an awareness of the certainty of death (and the uncertainty of the time
of death) serves to heighten the practitioner’s resolve for spiritual practice (Dalai Lama,
1995a).
Interconnectedness: The term ‘interconnectedness’ is utilized in Buddhism to refer to the
inter-being nature of all phenomena (Nhat Hanh, 1992). Each and every occurrence becomes
a causal condition for the arising of all subsequent occurrences throughout space and time.
For example, one person’s out-breath forms part of the next person’s in-breath, the decaying
corpse provides sustenance for the blossoming tree, and so on. Thus, phenomena are ‘empty’
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of an independent self but are ‘full’ of all things. Likewise, just as a wave is never separate
from the ocean, the human consciousness, despite its relapse into a state of ignorance, can be
considered inseparable from the realm of ultimate reality (Sanskrit: dharmadhatu; Pali:
dhammadhatu) (Rabjam, 2002).
Emptiness: ‘Emptiness’ is closely related to the principle of ‘non-self’ but takes on a greater
level of profundity whereby all phenomena are deemed to be ‘empty’ of intrinsic existence
(including the concept of emptiness itself). According to the Prajnaparamita-Hrdaya sutra
(more commonly known as the Heart sutra – a key Buddhist teaching on emptiness), ‘form is
emptiness and emptiness is form’ (Soeng, 1995). The meaning of this phrase is profound and
it implies that for the enlightened being, ‘Samsara’ (i.e., the mundane world of birth,
suffering, death, and rebirth) and ‘Nirvana’ (i.e., the state of total liberation) are in fact one
and the same thing. Indeed, a full realization of emptiness represents the quintessence of
Buddhist practice and emptiness is intrinsically interrelated with each of the aforementioned
‘wisdom’ constructs. For example, at a more subtle level, impermanence refers to the
moment-by-moment transitory nature of existence (Dalai Lama, 2005). According to this
view, phenomena are changing all of the time. Nothing remains static for even an instant.
However, if phenomena are in a state of constant flux, then at what point can it be said that
they actually ‘exist’ in order to undergo change? Thus, the self-contradictory nature of
impermanence can, in this manner, be used as a ‘key’ for intuiting emptiness.
Nagarjuna (2nd c. AD) fathered the Buddhist Madhyamaka school of reasoning which asserts
a ‘middle way’ between the diametrically opposed extremes of ‘inherent existence’ and
‘nihilism’. However, rather than becoming ‘attached’ to the concept of a middle-way,
Nagurjuna advocated complete freedom from the trappings of inflexible dualistic (e.g., self
and other, good and bad, one or the other, etc.) conceptualizations. In other words, even the
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middle-way standpoint has to be relinquished because if the extremes of existence and
nihilism are both belied, then the concept of a ‘middle-way’ is also rendered untenable. Thus,
emptiness does not deny that phenomena appear but requires ‘non-conceptualization’ in order
to intuit the true and absolute manner in which such appearances abide (Huang Po, 1982).
Original nature: Terms such as the ‘original nature of Mind’ occur throughout the Buddhist
literature but particularly so in certain Vajrayana and Zen Buddhist contexts (Zen Buddhism
is typically regarded as a Mahayana Buddhist vehicle but aspects of the more esoteric Zen
approaches might actually be more consistent with Vajrayana practice). The word ‘Mind’ is
often capitalized in this context to denote the ‘primordially enlightened Mind’ as opposed to
the ‘everyday mind’ with its various emotional and knowledge-based limitations. The phrase
‘nature of Mind’ is used to express the view (or realization) that all phenomena are ‘Mind-
born’ (Norbu & Clemente, 1997). This is a somewhat ineffable concept that is perhaps best
illustrated via the analogy of a dream. Various psychosomatic sleep-state symptoms including
anxious arousal, sudden screaming, and increased autonomic discharge (e.g., tachycardia,
increased respiratory amplitude, and perspiration) have been correlated with bad dreams and
nightmare disorder as defined in the DSM-IV-TR (Zadra & Donderi, 2000). Therefore,
although the entire dream experience is generally considered to be ‘unreal’ and self-
produced, it is nevertheless experienced as ‘real’ at the time of dreaming. According to
Buddhist exponents of this view, the mode of abiding of everyday waking reality exists in
much the same manner (Dalai Lama 2004; Urgyen, 2000). Although phenomena certainly
appear, they are considered (or experienced) to be illusory, without substance, and are
deemed to be non-other than Mind’s luminous spontaneous display (Dudjom, 2005). As
stated by the Buddha: “One who looks upon the world as a bubble and a mirage, him the
King of Death sees not” (as cited in Buddharakkhita, 1966, p.67). ‘Wake-up’, is therefore a
term sometimes employed by Buddhist teachers (e.g., Norbu & Clemente, 1997) to refer to
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the process of recovering from ontological addiction and awaking from the deep-sleep of
primordial ignorance (Shonin et al., 2013b).
Current Directions
In contrast with treatment approaches based on the Buddhist practices of mindfulness or
compassion, the clinical utilization of Buddhist wisdom techniques has progressed at a slower
pace. Nevertheless, since 2010, several interventions have become operational that attempt to
integrate Buddhist wisdom techniques as the central therapizing component. An example is
Buddhist Group Therapy (BGT), a six-week program (weekly sessions of two-hours
duration) in which participants partake in mindfulness practice, diary keeping, sharing of
personal stories, and tutoring in the Buddhist ‘wisdom’ principles of suffering,
impermanence, and selflessness (Rungreangkulki, Wongtakee, & Thongyot, 2011). Diabetes
patients (n = 62) of Buddhist background with depression who received BGT evinced
significant reductions in anxiety over treatment-as-usual controls.
A further and more recent example is Meditation Awareness Training (MAT) (Van Gordon et
al., 2013). MAT is an eight-week group-based secular intervention and employs a
comprehensive approach to meditation whereby mindfulness practice is an integral part but
does not form the exclusive focus of the program. MAT is grounded in the three Buddhist
principles of wisdom, meditation, and ethical awareness, and includes practices designed to
cultivate ethical awareness, patience, generosity, loving kindness, and compassion. The
intervention also integrates concentrative and insight meditation techniques in order to
encourage a gradual familiarization with concepts such as impermanence and emptiness. In a
controlled pilot trial of MAT (n = 25), a sub-clinical sample of university students with issues
of stress, anxiety, and depression demonstrated significant improvements over controls in
psychological distress and dispositional mindfulness (Van Gordon et al., 2013). In a further
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recent study of MAT, participants (with issues of stress, anxiety, and depression) experienced
a growth in personal agency and a greater willingness to relinquish rigid habitual behavioral
patterns which they attributed to preliminary meditative-born insights into emptiness and
impermanence (Shonin et al., 2013a).
In addition to the direct evaluation of interventions such as MAT and BGT, empirical support
for the clinical utilization of Buddhist ‘wisdom’ principles is derived from cross-sectional
studies. An example is a cross-sectional study (comprising 511 adults and 382 students) by
Sahdra et al (2010) who found that ‘non-attachment’ predicted greater levels of mindfulness,
acceptance, non-reactivity, self-compassion, subjective wellbeing, and eudemonic wellbeing.
The same authors also demonstrated that the Buddhist non-attachment construct was
negatively correlated with avoidance (of intimacy), dissociation, fatalistic outlook, and
alexithymia (i.e., a deficiency in recognising or describing feelings).
Further support for the clinical application of Buddhist wisdom practices comes from the tacit
or explicit utilization of such practices within psychotherapeutic modalities more generally.
For example, Segall (2003) identified the extent to which Buddhist principles are engrained
within various cognitive-behavioral and experiential psychotherapies such as CBT and
Gestalt Therapy. It is also well-known that Albert Ellis’ Rational Emotive Behavior Therapy
is heavily influenced by the Buddhist view that attachment and self-grasping lie at the roots
of suffering (Christopher, 2003). Furthermore, aspects of Zen Buddhist practice have been
shown to support Smith’s (1999) ABC (e.g., Attentional, Behavioral, and Cognitive) theory
of relaxation via a mechanism of non-attachment to cognitive arousal which begets increases
in mental quietude and relaxation (Gillani & Smith, 2001).
Indeed, according to Chan (2008), meditation on ‘non-self’ can complement therapeutic
techniques that work at the surface level of behavior and cognition via a mechanism of
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gradually uprooting egoistic core beliefs. Sills and Lown (2008) use terms such as ‘witness
consciousness’ to refer to the process of therapeutic reconnection and transformation that
takes place as client and therapist begin to widen their view of self and work in an “open and
empty ground state” (p.80). Thus, an understanding of non-self can enhance therapeutic core
conditions because “the more the therapist understands annata [non-self], the less likelihood
that the therapy will be about the selfhood of the therapist” (Segall, 2003, p.173).
The Buddhist principle of impermanence perhaps warrants additional discussion due to its
potential utility for facilitating recovery from trauma and grief. Traditional Western models
of grief are based on a phasic bereavement process and normally involve stages of (i) shock
(ii) distress and denial, (iii) mourning, and (iv) recovery (e.g., Jacobs, 1993). However, a
greater familiarization with the impermanent nature of life may exert a form of resilience
effect. For example, Wada and Park (2009) suggest that increased acceptance and
internalization of impermanence may help to soften the grieving process and facilitate earlier-
onset of the recovery and restorative phases. Similarly, Kumar (2005) posits that
impermanence awareness can assist post-traumatic growth due to a “radical acceptance” of
the transitory and precious nature of human existence (p.8).
Clinical Integration Issues
Although preliminary findings indicate clinical utility for Buddhist-derived wisdom practices,
empirical evaluation of this area of Buddhist practice is at an early stage. Findings should
therefore be considered in light of their limitations. For example, both the MAT and BGT
quantitative studies (i.e., Van Gordon et al., 2013; Rungreangkulki et al. 2011) were limited
by (i) small sample sizes, (ii) between-group baseline differences in medication status or
levels of psychological distress, and (iii) the absence of an active control group. Furthermore,
concepts such as non-self and emptiness are subtle, complex, and somewhat tangential to
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conventional Western thought. Rather than a data-driven or academic understanding,
Buddhism emphasizes the need for regular and prolonged meditation practice so that the
‘realization’ of such teachings can arise intuitively. Therefore, there are risks associated with
concepts such as non-self (Michalon, 2001) that if misunderstood (or incorrectly taught),
could easily accentuate any delusional schemas or give rise to defeatist, nihilistic, and/or
psychosocially maladaptive beliefs. Additional caution is therefore recommended prior to
considering such techniques as viable options for patients with cognitive impairment and/or
reality-distortion complexes.
Meditation: Calming and Training the Mind
Meanings
Arguably, the two Buddhist terms related to meditation that are most widely applied in the
clinical literature are ‘meditation’ (including concentrative meditation and insight meditation)
and ‘mindfulness’.
Meditation: Buddhist meditation involves a process of training and developing the mind, and
most forms of Buddhist meditation integrate both concentrative (or serenity) and analytical
(or insight) components (Dalai Lama, 2001)v. Concentrative or ‘tranquil abiding’ meditation
(Sanskrit: shamatha; Pali: samatha) involves the calming of afflictive cognitive and
emotional states whereas insight or analytical meditation (Sanskrit: vipashyana; Pali:
vipassana) is the process of uprooting such afflictions (Rabjam, 2002). Therefore, in order to
switch from samatha meditation to vipassana meditation, a subtle yet deliberate shift in
meditative-mode is required in order to penetrate the ‘truth’ (i.e., the absolute mode of
arising) of a particular object (such as the self) (Kongtrul, 1992). This depiction of samatha
18
and vipassana meditation is not only consistent with the Tibetan and general Mahayana
Buddhist view (e.g., Dalai Lama & Berzin, 1997; K’uan Yu, 1976), but also with the
Theradava Buddhist perspective (e.g., Chah 2011; Maha Boowa, 1997, Nyanatiloka, 1980)vi.
Indeed, according to the Buddha’s words as captured in the Mahavacchagotta sutra
(Majhmima Nikaya sutra 73): “When these two things – serenity and insight – are developed
further, they will lead to the penetration of many elements” (Bodhi, 2009, p.600). Likewise,
at various points in the Anguttara Nikaya (one of the five collections of sutras that
collectively comprise the Sutra Pitaka – the basket or division of the Buddhist canon
comprising the Buddhist sutras), direct reference is made to the “coupling or yoking of
tranquillity and insight” (i.e., samatha-vipassana) in order to reach the stage where “all
ignorance is abandoned” (Nyanatoloka, 1980, p.194).
At the initial stages, samatha meditation typically involves the use of a reference-point or
‘object of placement’ in order to help anchor the mind (Ponlop, 2003). One-pointed
concentration on objects such as the breath or a visualized object (normally of spiritual
significance such as the Buddha), are typical examples of objects of placement. At more
advanced stages, samatha meditation can be practiced with a much broader attentional aspect
whereby present moment experience becomes the object of placement (Ponlop, 2003).
Mindfulness: As part of the practice of meditation, mindfulness is the process of ensuring that
the mind remains concentrated on the object of placement. Mindfulness therefore involves an
observance of emotional and cognitive processes (such as ‘mental formations’; Sanskrit:
samskara; Pali: sankhara) that might otherwise result in a loss of concentration. Vigilance is
a concept related to mindfulness and refers to the quality of awareness that oversees and
regulates mindfulness. In other words, mindfulness ensures that the mind does not wander
from the object of placement and vigilance observes that mindfulness is intact (Dalai Lama,
19
1997). Buddhism emphasizes the importance of maintaining meditative awareness beyond
formal meditation sessions. In fact, the more advanced meditator should essentially be aiming
to practice ‘non-meditation’, in which no distinction is made between meditation and post-
meditation periods (Dudjom, 2005). Therefore, mindfulness plays a vital role in the
integration of meditative awareness into everyday life.
Amongst contemporary Buddhist scholars, there is a sensible level of agreement that the term
‘mindfulness’ is an acceptable interpretation of both the Pali word ‘sati’ and the Sanskrit
word ‘smrti’. However, it is should be noted that there are different interpretations of both of
these terms, and therefore depictions of the Sanskrit term ‘smrti’ and the Pali term ‘sati’ may
not always be identical. For example, the Sanskrit root ‘sat’ means ‘truth’ or ‘to exist’, and so
if it is accepted that the Pali term ‘sati’ is a transformed borrowing from the Sanskrit ‘sat’
(i.e.,. as opposed to being part of the Prakrit lexicon), then the Pali term ‘sati’ might be
construed as meaning the ‘awareness of the existence of experienced phenomena in a given
moment’. This would be distinct from certain interpretations of both sati and smrti that, from
the Buddhist perspective, are less satisfactory due to depicting mindfulness as the faculty of
‘remembering’ or ‘recollecting’ (see review of mindfulness definitions by Gethin, 2011).
However, given that both the Sanskrit root ‘smr’ and the Pali ‘sati’ can also denote ‘intense
thought’ (Har, 1999), ‘mental activity’ (Rhys Davids, 1881), or ‘intense cognition’, then in
the context of Buddhist meditative practice it seems acceptable to render both of these terms
as meaning ‘full retention of mind’ or ‘full awareness of mind’ (and therefore mind objects)
in the present-moment (i.e., rather than the remembrance of past events). Slight variations in
the meanings and interpretations of these terms are likely to be one reason (amongst others)
why mindfulness is interpreted and operationalized differently by different Buddhist
approaches (see, for example, Kang & Whittingham, 2010; Rosch, 2007).
20
Despite the abovementioned variations in how Buddhism construes mindfulness, the notion
of present moment awareness is regarded by all Buddhist traditions as a central component of
mindfulness practice. This present moment awareness generally refers to a full awareness of
processes relating to: (i) body, (ii) feelings, (iii) mind, and (iv) phenomena (collectively
known as the four ‘Establishments of Mindfulness’; Pali: satipatthana; Sanskrit:
smṛtyupasthana; Nyanaponika, 1983). Anapanasati is a Pali word (Sanskrit: anapanasmṛti)
which means ‘mindfulness of breathing in and out’ and is a method of arousing the four
establishments of mindfulness by using the breath to ‘tie the mind’ to the present moment
while awareness is directed, in turn, to each of the four abovementioned focus points (i.e.,
body, feelings, mind, and phenomena) (see the Anapanasati sutra; Majjhima Nikaya sutra
118; Bodhi, 2009). Thus, mindfulness is essential for (i) maintaining meditative awareness,
(ii) subduing discursive and ruminating thought processes (Nyanaponika, 1983; Teasdale,
Segal, & Williams, 1995), and (iii) cultivating a state of mind conducive to spiritual
awakening (Sanskrit: bodhipakṣa dharma; Pali: bodhipakkhiya dhamma).
Current Directions
Mindfulness meditation has been shown to be efficacious for the treatment of health
conditions ranging from depression, anxiety, bipolar disorder, sleep disorder, and substance-
use disorders, to human immunodeficiency virus, coronary heart disease, chronic pain,
fibromyalgia, and cancer (for recent reviews, see Chiesa et al., 2011; Chiesa & Serretti, 2011;
de Vibe, Bjørndal, Tipton, Hammerstrøm, & Kowalski, 2012; Eberth, & Sedlmeier, 2012;
Fjorback, Arendt, Ørnbøl, Fink, & Walach, 2011; Hofmann, et al., 2010; Klainin-Yobas,
Cho, & Creedy, 2012; Shonin, Van Gordon, Slade, & Griffiths, 2013; Vøllestad et al., 2011).
Discounting a small number of exceptions where no reliable effect was reported (e.g.,
Toneatto & Nguyen, 2007), the strongest meta-analytical effect sizes (e.g., Hedges’ g > 0.85)
21
are typically evinced for the treatment of mood and anxiety disorders (Hofmann et al., 2010;
Vøllestad et al., 2011). However, effect sizes generally fall into the small to moderate range
for the treatment of somatic illnesses (e.g., Baer, 2003; Grossman, Niemann, Schmidt, &
Walach, 2004; Ledesma & Kumano, 2009).
Group-based interventions using mindfulness meditation typically adhere to an eight-week
secular format and comprise: (i) weekly sessions typically of three hours duration, (ii) guided
mindfulness exercises, (iii) yoga exercises, (iv) a CD of guided meditations to facilitate daily
self-practice, and (v) an all-day silent retreat component (Shonin et al., 2013c). The two most
established techniques are ‘Mindfulness-Based Stress Reduction’ (MBSR; Kabat-Zinn, 1990)
and Mindfulness-Based Cognitive Therapy (MBCT; Segal, Williams, & Teesdale, 2002).
Variants of MBSR and MBCT include interventions such as ‘Mindfulness-Based Relapse
Prevention’ (Bowen et al., 2009) for the prevention of relapse following rehabilitation from
substance use disorders, Mindfulness-Based Childbirth and Parenting for maternal wellbeing
during (and post-) pregnancy (Duncan & Bardacke, 2010), and Mindfulness-Based Eating
Awareness Training for treating binge eating disorders (Kristeller & Wolever, 2011).
Mindfulness is also integrated into a number of cognitive-behavioral one-to-one therapeutic
modes such as Dialectic Behavior Therapy (Linehan, 1993) and Acceptance and
Commitment Therapy (Hayes, Strosahl, & Wilson, 1999) (for a review of the
differences/commonalities between the various mindfulness-based interventions, see Chiesa
& Malinowski, 2011).
Other forms of Buddhist-derived meditative interventions to be applied in clinical contexts
include Vipassana Meditation (VM), a technique devised by Satya Narayan Goenkavii (for
reviews, see Chiesa, 2010; Shonin et al., 2013c). The VM program is generally conducted in
silence as part of a standardized 10-day retreat and includes the use of pre-recorded
22
discourses on various Buddhist principles. Studies of VM have demonstrated a range of
salutary effects – particularly for incarcerated samples. Examples of outcomes from VM
studies in minimum and maximum security correctional settings include: (i) reductions in
substance use, alcohol use, and alcohol-related negative consequences (Bowen et al., 2006),
(ii) reductions in thought suppression (Bowen, Witkiewitz, Dillworth, & Marlatt, 2007), and
(iii) improvements in levels of mindfulness, emotional intelligence, and mood disturbance
(Perelman et al., 2012).
Clinical Integration Issues
Although there is a growing body of evidence that attests to the clinical utility of VM and
mindfulness-based interventions (MBIs), a number of factors limit the overall validity of
empirical findings. Examples of such factors are: (i) an over-reliance on self-report measures
rather than clinical diagnostic interviews, (ii) poorly designed control interventions that do
not account for non-specific factors such as therpeutic alliance, psychoeducation, or physical
exercise, (iii) fidelity of implementation not assessed (i.e., to control for deviations from the
standard intervention format), (iv) absence of (or poorly implemented) intent-to-treat
analysis, (v) variations in the experience and competance of program instructors, (vi)
adherance to practice data not elicited, and (vii) heterogeneity between different MBIs in the
usage of other Buddhist techniques such as loving-kindness meditation (Van Gordon et al.,
2013).
There are also integration issues concerned with the availiability of MBIs for service users.
For example, only 20% of general practitioners in the United Kingdom report being able to
access MBIs for their patients (MHF, 2010). Similarly, although based on aspects of Buddhist
23
practice, MBIs do not necessarily represent culturally syntonic treatments for all Asian
Americans and Asian Europeans, including those of Buddhist descent (Hall et al., 2011). For
example, many lay Asian Buddhists do not practice meditation and may not even be familiar
with Buddhist concepts such as emptiness and interconnectedness (see Hall et al., 2011). In
fact, compared to the average dedicated Western lay Buddhist, it is probably accurate to say
that the practice of the average lay Asian Buddhist is more orientated towards ‘gaining merit’
(i.e., positive karma) and observing Buddhist ethics in order to be reborn in conditions (such
as a Buddhist monk) that are more conducive to intensive spiritual practice.
Other integration issues relate to the credibility and competance of MBI program instructors.
For example, although there are currently attempts to disseminate best-practice and
assessment guidelines for MBI teachers (see Crane et al., 2011; Crane et al., 2013), as yet,
there are no dedicated regulation and accreditation bodies to stipulate minimum competency
levels for MBI instructors. Indeed as it stands, MBI instructors may have as little as 12
months’ mindfulness practice and teaching experience following completion of a single
eight-week course (MHF, 2010).
Arguably, the most commonly reported integration issue relating to MBIs is that there
remains a lack of consensus within psychology in terms of what defines the mindfulness
construct (see Chiesa, 2012; Kang & Whittingham, 2010). Many of the issues in this debate
relate to the extent to which Western psychological depictions of mindfulness are consistent
with traditional Buddhist perspectives. Given that it is common for MBIs to proclaim a
certain ‘grounding’ in Buddhist practice, this may be potentially confusing (or even
misleading) for service-users because it is questionable whether mindfulness meditation, as
used in MBIs, continues to resemble the faculty of ‘right mindfulness’ as it is construed by
the Buddhist teachings (Shonin et al., 2013a). Indeed, the term ‘mindfulness meditation’ is
24
actually not common to the Buddhist lexicon as in general the technique is simply referred to
as ‘mindfulness’. Key examples of how Western psychological portrayals of mindfulness
may differ from the traditional Buddhist perspective are described below, and illustrative
questions that may help to inform scientific debate regarding how best to define and integrate
mindfulness within clinical contexts are outlined in Table 1.
1. Context for practice: Within Buddhism, mindfulness is practiced in conjunction with
numerous other practices and perspectives and is just one aspect (the seventh aspect)
of a key Buddhist tenet known as the Noble Eightfold Path. In particular, the
successful establishment of mindfulness relies upon a deep-seated understanding of
the three root principles of wisdom, meditation, and ethical awareness - all of which
interact to form a cohesive whole. Thus, concerns have therefore arisen relating to
whether MBIs lack ‘foundational congruence’ and whether the ‘spiritual essence’ and
full potential treatment efficacy of mindfulness has remained intact in its clinically
orientated and Westernized form (Howells, Tennant, Day, & Elmer, 2010;
McWilliams, 2011; Rosch, 2007; Singh, Lancioni, Wahler, Winton, & Singh, 2008;
Shonin et al., 2013d; Van Gordon et al., 2013). Thus, there is an urgent need for
Western psychologists to determine and clarify whether, in addition to alleviating
psycholgical and/or somatic distress, MBIs are also primarliy intended (and provide
the necessary infrastructure) to spiritually empower their participants.
2. Non-judgemental awareness: According to Kabat-Zinn (1994), mindfulness is the
process of “paying attention in a particular way: on purpose, in the present moment,
and non-judgmentally” (p.4). Although there is agreement between Western
psychological and (all of the) Buddhist perspectives that mindfulness is fundamentally
concerned with becoming more aware of the present moment, the statement that
mindfulness necessitates a ‘non-judgemental’ awareness requires closer examination.
25
Insofar as the term ‘non-judgemental’ implies that the mindfulness practitioner should
accept (i.e., and not try to reject or ignore) present-moment experiences then it is
likely that most Buddhist traditions would agree that this is an appropriate term.
However, the term ‘non-judgemental’ could also imply that the mindfulness
practitioner doesn’t seek to discern which cognitive, emotional, and behavioral
responses are conducive to the upholding of ethical commitments and to spiritual
development more generally. This would obviously be inconsistent with the Buddhist
perspective. Thus, a more comprehensive elucidation by Western psychologists of the
intended meaning of the term ‘non-judgemental’ is required in order to reconcile
ambiguity concerning the use of this term.
3. Insight generation: In the clinical literature, the terms ‘vipassana meditation’ and
‘insight meditation’ are frequently used interchangeably with the term ‘mindfulness
meditation’. Indeed, ‘vipassana meditation’ is often referred to as a form of
meditation in which awareness is directed in a non-reactive manner to the stream of
internal thoughts, emotions, perceptions, and so forth, as they spontaneously arise in
the present moment (e.g., Bowen et al., 2006; Chiesa, 2010; Sills & Lown, 2008).
However, this depiction of vipassana meditation (and insight meditation) is
inconsistent with the traditional (and already outlined) Theravada, Mahayana, and
Vajrayana Buddhist perspectives. In these traditional contexts, vipassana meditation
refers to the use of (various styles of) penetrative analysis in order to give rise to
transcendent insight or wisdom (e.g., Bodhi, 2009 [e.g., see Majjhima Nikaya sutra
73]; Chah, 2011; Dalai Lama, 2001; K’uan Yu, 1976; Maha Boowa, 1997;
Nyanatiloka, 1980; Rabjam, 2002). In fact the terms ‘vipassana meditation’ and
‘insight meditation’, as used in the clinical literature, more accurately describe the
26
practices of mindfulness or certain forms of open-aspect concentrative meditation
(sometimes referred to as ‘samatha without reference’).
One possible source of this confusion are contemporary (i.e., 20th/21st century) and
primarily Theravada-derived Buddhist “Insight Meditation” movements such as the
one initiated by Satya Narayan Goenka (see previous subsection on ‘Current
Directions’) in which vipassana meditation is depicted as being similar to mindfulness
meditation. However, rather than a form of mindfulness practice (as implied by
Goenka and certain Western psychologists), the classical Buddhist teachings explicate
that vipassana (which actually means ‘superior seeing’) involves a different and more
investigative meditative mode that can only be applied after first calming and placing
the mind using samatha techniques (see above section on the ‘Meanings’ of the terms
‘meditation’ and ‘mindfulness’). This is certainly not to say that Goenka’s and certain
other contemporary styles belonging to the Insight Meditation movement are not
‘authentic’ in their transmission of the Buddhadharma (because they undoubtedly
are). However, it does mean that their use of certain Buddhist terms is not always
consistent with the traditional construal. Furthermore, although mindfulness
meditation certainly leads to the generation of insight in the sense that it facilities (for
example) a better understanding of “the nature of thoughts and feelings as passing
events in the mind” (Bishop et al., 2004, p.234), mindfulness meditation is not insight
meditation as per the traditional Buddhist technique. Thus, for the purposes of
avoiding (further) inconsistency, terminological accuracy, and confusion in the
clinical psychology literature, it is the view of the present authors that any
contemporary system that differs from the interpretation of samatha and vipassana
meditation as depicted in the classical Buddhist (Theravada, Mahayana, and
Vajrayana) literature, should not be adopted by Western clinicians and researchers.
27
Although there is an urgent need for greater clarity relating to several aspects of the Western
psychological mindfulness formulation, rather than academicians striving to devise and
disseminate an ‘all-encompassing model and definition’ of mindfulness, one insightful means
of reconciling aspects of the ‘mindfulness definition debate’ might be to just accept that “the
definition of mindfulness will vary depending on whether one is interested in mindfulness
from a social psychological, clinical, or spiritual context, or from the perspective of a
researcher, clinician, or a practitioner, and their various combinations” (Singh, 2008, p.
661). Similarly, it is improbable that an absolute definition of mindfulness will ever be
formulated because as a spiritual phenomenon, certain dimensions of the mindfulness
construct will always be somewhat ineffable and only fully understood by those individuals
who can tap into them on the experiential rather than empirical or academic plane.
--------------------------------
Insert Table 1 about here
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Ethical Awareness: Constructive Thoughts and Behaviors
Meanings
Terms frequently employed in the clinical literature that can be subsumed under the heading
of ethical awareness include ‘ethical discipline’ (also referred to as ‘ethical awareness’) as
well as more conduct-related terms such as ‘generosity’, ‘patience’, ‘loving kindness’, and
‘compassion’.
Ethical discipline: Ethical discipline lies at the roots of Buddhist practice and serves to ensure
that spiritual progress does not fall prey to ‘spiritual materialism’ (Trungpa, 2002) or become
28
derailed by mundane aspirations. Tsong-kha-pa (2004) defines ethical discipline as “an
attitude of abstention that turns your mind away from harming others and from sources of
such harm” (p.143). Without ethical awareness in terms of which actions (of body, speech,
and mind) to adopt and which to reject, then constant craving for sensory or emotional
gratification prevents meditative quiescence from arising (Dalai Lama, 1999). Various
systems (or combined systems) of precepts are used as supports for observing ethical
discipline (e.g., the Pratimoksha vows of Theravada Buddhism, the Bodhisattva vows of
Mahayana Buddhism, the Samaya vows of Vajrayana Buddhism).
Precepts are not imposed as a series of rigid rules. Rather, they serve to synchronize spiritual
practice with the ‘law of the effects of actions’ (karmic law). The Buddha advocated a
middle-way between the behavioral extremes of over-indulgence and total abstinence
(Nanamoli, 1979). However, rather than the avoidance of certain experiences or situations,
the most essential point is that actions should be governed by a complete freedom from
attachment or aversion. For example, in the Mahasakuludayi sutra, the Buddha explains that
he sometimes eats “choice rice and many sauces and curries”, lives “in gabled mansions”
and acquaints with “kings and king’s ministers”, yet such activities do not affect his virtue or
wisdom (Bodhi, 2009, pp. 633-634). Thus, for the highly experienced practitioner who is free
from attachment, ethical awareness transcends any concept of right or wrong (Rabjam, 2002;
Trungpa, 2003).
Generosity: Rather than Western psychology’s construction of generosity (or altruism) as
concern for the welfare of others (Batson, 2011), Buddhism conceptualizes generosity more
as a dedication and unconditional giving of one’s entire being (e.g., presence, time, and
meditative insight) and resources (including spiritual teachings) for the benefit of others
29
(Dalai Lama, 1995b). Most importantly, this begins with altruism and kindness towards
oneself.
Patience: Patience is born from generosity and nourishes the practitioner with fortitude to
endure the challenges of spiritual practice as well as the wrongs inflicted by others.
Santideva, an eighth century Indian Buddhist saint states that “the mind does not find peace,
nor does it enjoy pleasure and joy, nor does it find sleep or fortitude when the thorn of hatred
dwells in the heart” (1997, p.60). According to the Buddhist view, patience leads to
contentedness and a state of open acceptance to the present moment and is therefore a key
attribute of mindfulness. The Buddhist idea of perfected patience is a state beyond all hope
and fear and beyond any desire to modify the present moment.
Loving kindness and compassion: Loving-kindness refers to the wish for all beings to have
happiness and its causes while compassion refers to the wish for all beings to be free from
suffering and its causes (Bodhi, 1994). Within the Tibetan lojong (‘mind training’) modality,
a meditation technique known as tonglen or ‘giving and taking’ involves ‘straddling’ the
visualization practices of ‘taking’ others’ suffering and ‘giving’ one’s own happiness astride
the in-breath and out-breath respectively. In this manner, ‘giving’ could be regarded as the
meditative actualization of loving kindness and ‘taking’ as compassion.
The Buddhist construal of loving kindness and compassion does not involve any sense of pity
and is perhaps best elucidated within the framework of the Four Immeasurable Attitudes
(Sanskrit: catvari brahmaviharahs; Pali: cattari brahmaviharas) of (i) joy, (ii) loving
kindness, (iii) compassion, and (iv) equanimity. Joy (as one of the four immeasurable
attitudes) emphasizes the Buddhist view that loving kindness and compassion can only be
forged from a mind that is already pacified and ‘well-soaked’ in meditative bliss.
‘Equanimity’ stresses the need for unconditionality and impartiality in the cultivation of
30
loving kindness and compassion that are extended in equal and unlimited measure to all
sentient beings irrespective of whether they be friend or foe (for an in-depth elucidation of
the Four Immeasurable Attitudes see the ‘Vissuddhi Magga’ [an important Buddhist treatise
on ‘The Path of Purification’]; Nanamoli, 1976). Each of these conduct-related practices
(e.g., generosity, patience, loving kindness, and compassion) should be conducted free from
any dualistic view. For example, when compassion is suffused with emptiness, and therefore
stems from a realization that there is no self (and hence no giver) and no other (and hence no
receiver), then, according to Buddhist teachings, acts of ‘great compassion’ (Sanskrit and
Pali: maha karuna) can arise spontaneously (Khyentse, 2007; Trungpa, 2003).
Current Directions
In the last ten years, compassion meditation (CM) and loving-kindness meditation (LKM)
have been the subject of increasing clinical interest (for reviews, see Hofmann, Grossman, &
Hinton, 2011). This is consistent with the growth of publications relating to CM and LKM in
mainstream Western meditative culture (e.g., Chodron, 1996). Accordingly, a number of
novel interventions have been formulated with the intention of operationalizing CM and
LKM as palatable techniques for Western service-users. Of notable interest is an intervention
known as Cognitively-Based Compassion Therapy (CBCT; Pace et al., 2009). CBCT is a
group-based six-week (or similar) long secularized intervention based on the Tibetan
Buddhist ‘mind training’ technique. Participants attend weekly or twice-weekly classes
ranging from 50 minutes to two hours duration and receive instruction on meditative
practices intended to cultivate self-compassion and compassion.
Outcomes from recent studies of CBCT include: (i) reductions in innate immune and distress
responses to psychosocial stress in healthy adults (Pace et al., 2009), (ii) reductions in
salivary concentrations of C-reactive protein (a health-relevant inflammatory biomarker for
31
psychopathology) in adolescents with high rates of early-life adversity (Pace et al., 2012),
(iii) reductions in levels of depression for adolescents at-risk for psychopathology (Reddy et
al., 2012), (iv) improvements in empathic arousal in healthy adults (Mascaro, Rilling, Negi,
& Raison, 2012), and (v) increased emotion regulation capacity as evinced by increases in
right amygdala responses to an image-based emotion eliciting task (Desbordes et al., 2012).
A further technique incorporating compassion practices is Compassion-Focussed Therapy
(CFT; Gilbert, 2009). CFT is a one-to-one therapuetic mode in which clients/patients
typically attend one-hour sessions over a twelve-week period. CFT integrates a technique the
author terms ‘compassionate mind training’ whereby a client’s shameful and self-disparaging
tendancies are displaced by therpist-led compassionate regard. Outcomes from several small
pilot studies suggest that CFT may help to (i) reduce anxiety and depression in patients with
chronic mood disorders, and (ii) reduce hostile auditory hallucinations in patients diagnosed
with paranoid schizophrenia (Gilbert & Procter, 2006; Mayhew & Gilbert, 2008).
Recent studies have also returned promising findings for the clinical utilization of LKM.
Participants of LKM interventions are typically instructed to direct feelings of love and
kindness firstly towards themselves, then towards a neutral person (e.g., the postman),
towards a person who was a source of difficulty (e.g., a disrespectful former boss), and
finally towards all living beings (Carson et al., 2005). Similar to CM interventions, LKM
interventions are normally group-based and of a secular nature. Participants attend weekly
sessions (1 to 2 hours duration) over a six- to eight-week course and receive a CD of guided
meditations to facilitate daily self-practice.
Outcomes of recent LKM intervention studies include: (i) reductions in pain intensity and
psychological distress in patients with chronic lower back pain (Carson et al., 2005), (ii)
improvements in asociality, blunted affect, self-motivation, interpersonal relationships, and
32
relaxation capacity in patients diagnosed with a schizophrenia-spectrum disorder (Johnson et
al., 2009), and (iii) improvements in anhedonia, intensity of positive emotions,
consummatory pleasure, environmental mastery, self-acceptance, and satisfaction with life in
outpatients with a schizophrenia disorder (Johnson et al., 2011).
Clinical Integration Issues
It appears that CM and LKM interventions represent promising novel treatments for a broad
spectrum of psychological disorders. Nevertheless, findings from CM and LKM intervention
studies should be considered with caution due to being limited by factors such as: (i) small
sample sizes (sample sizes in the abovementioned studies ranged from three to 93
participants), (ii) differences between intervention and control groups in baseline
characteristics, (iii) fidelity of implementation not controlled for, (iv) poorly designed control
conditions, and (v) high attrition rates.
Caution is also recommended in the delivery of CM and LKM techniques in order to avoid
adverse treatment effects. For example, some care providers (e.g., nurses) have been
identified as at-risk for ‘compassion-fatigue’, a form of secondary traumatic stress incurred
during the provision of care to patients with illnesses of a distressing nature (or who have
experienced a traumatic event) (Yoder, 2010). For this reason, prior to embracing the
suffering of others (and acting unconditionally to alleviate that suffering), Buddhist
practitioners are first taught to cultivate emotional stability within themselves and to become
fully aware of the nature of their own suffering (Khyentse, 2007). Consistent with this
approach, higher levels of self-compassion (Thompson & Waltz, 2008) and mindfulness
(Follette, Palm, & Pearson, 2006) have both been shown to reduce maladaptive post-
traumatic avoidance strategies. Thus, there are certain risks associated with the practices of
compassion and loving kindness yet it appears that these can be mitigated via the prior
33
development of self-compassion and mindful awareness. In a similar vein, future clinical and
scientific enquiry could explore whether the Buddhist practices of joy and equanimity (i.e.,
the other two of the four Brahmaviharas) can augment the effectiveness of LKM and CM
interventions, or whether these practices have clinical utility in their own right.
Considering the complications involved in defining mindfulness, it is probable that attempts
to define CM and LKM will meet with similar operational challenges. Indeed, in addition to
the degree of ‘construct-overlap’ that exists between CM and LKM, there is also an element
of overlap between both of these meditative techniques and mindfulness meditation. For
example, Johnson et al (2009) describe LKM as a technique that “involves quiet
contemplation, often with eyes closed or in a non-focused state and an initial attending to the
present moment” (p.503) in which participants are instructed to “non-judgementally redirect
their attention to the feeling of loving kindness when attention wandered” (p.504). Based on
such descriptions, it is difficult to discern where mindfulness practice ends and LKM (or CM)
practice begins. Thus, an operational challenge for CM and LKM interventions is the need to
establish clear and accurate workable definitions as well as a thorough depiction of the
unique attributes of these techniques relative to other forms of meditation.
Conclusions
There is growing evidence for the salutary effects of BDIs in the treatment of
psychopathology. Although clinical interest has predominantly focussed on mindfulness
meditation, recent years have seen an increase of investigation into other Buddhist
techniques. Nevertheless, much remains to be done in terms of strengthening the evidence-
base for BDIs and for exploring currently ‘untapped’ ground. For example, Ekman,
34
Davidson, Ricard, and Wallace (2005) emphasize the pivotal role that Buddhist principles can
play in informing the direction of emotion-based research. Similarly, although there is some
research examining the role of patience as a predictor of adaptive psychosocial functioning
(e.g., Curry, Price, & Price, 2008), exploring the Buddhist dimensions of such qualities (e.g.,
non-reactivity, contentedness, desirelessness, etc.) may lead to greater application within the
clinical setting.
According to the Buddhist teachings, sustained ethically-informed and insight-driven effort
over a prolonged period of time are prerequisites for ‘sukha’ (a Sanskrit and Pali term
interpreted by Ekman et al [2005] as meaning ‘enduring psychological wellbeing’viii).
Therefore, a certain degree of realism is required in terms of what treatment outcomes can be
expected from BDIs of eight-week (or similar) duration. Indeed, treatment plans are likely to
benefit by factoring in regular meditation booster sessions as well as progressively more
advanced meditation or mindfulness training. Likewise, instructors of BDIs may wish to
consider the merits of receiving prolonged training in meditation so as to be able to impart an
embodied authentic transmission of the subtler aspects of meditation practice (Shonin et al.,
2013d). Of vital importance in this respect, is that clinicians who utilize Buddhist techniques
in client-patient contexts understand that the Buddhist approach to spiritual transmission is
one that encourages the individual to investigate and experience the potency of the Buddhist
teachings for themselves, and to awaken and then rely on the ‘teacher within’. This is
consistent with the Buddha’s dying words as recorded in the Mahaparinivana sutra (Digha
Nikaya sutra 16):
"Therefore, Ananda, be a lamp unto yourself, be a refuge to yourself. Take
yourself to no external refuge. Hold fast to the Truth as a lamp; hold fast to the
Truth as a refuge." - Buddha (as cited in Walshe, 1995).
35
Integration issues are an inevitable consequence of the migration of Buddhist practices from
Eastern to Western cultures, and from spiritual to clinical domains. Indeed, Buddhist practice
traditionally takes place in the context of spiritual development whereby enlightenment, a
state of total liberation and omniscience, is the ultimate goal. Therefore, one obvious concern
that Buddhist teachers are likely to have regarding the ongoing integration of Buddhist
practices into clinical psychology is that rather than being employed for the purposes of
eliciting favourable treatment outcomes for patients with psychological disorders, the
Buddhist teachings could actually be used to help patients achieve much more of their full
human potential.
Evidently, there is a degree of confusion within the clinical and psychological literature
relating to the appropriate usage of certain Buddhist terms and practices. Consequently, there
is a need for greater dialogue between experienced Buddhist teachers and psychopathology
clinicians and researchers in order to establish robust operational foundations for BDIs. There
is also a need for greater disciplinary dialogue so that clinicians and researchers adopt a
unified and structured approach towards the clinical implementation of Buddhist practices.
Such dialogues will not only be paramount in safeguarding the ethical values, efficacy, and
credibility of BDIs, but will also help to preserve the authenticity of the Buddhist teachings
more generally.
36
References
American Psychiatric Association. (2010). American Psychiatric Association Practice
Guideline for the Treatment of Patients with Major Depressive Disorder (3rd ed.).
Arlington, VA: American Psychiatric Publishing.
Baer, R. (2003). Mindfulness training as a clinical intervention: A conceptual and empirical
review. Clinical Psychology: Science and Practice, 10, 125-143.
Baltes, P. B., & Staudinger, U. M. (2000). Wisdom: A metaheuristic (pragmatic) to
orchestrate mind and virtue toward excellence. American Psychologist, 55, 122-136.
37
Batson, C. (2011). Altruism in Humans. New York: Oxford University Press.
Bishop, M., Lau, S., Shapiro, L., Carlson, N. D., Anderson, J. & Carmody-Segal, Z. V., …
Devins, G. (2004). Mindfulness: A proposed operational definition. Clinical Psychology:
Science and Practice, 11, 230-241.
Bodhi, B. (1994). The Noble Eightfold Path: Way to the End of Suffering. Kandy, Sri Lanka:
Buddhist Publication Society.
Bodhi, B. (Ed.). (2009). Majjhima Nikaya: The Middle Length Discourses of the Buddha (4th
ed.). (Bhikkhu Bodhi, & Bhikkhu Nanamoli, Trans.) Massachusetts: Wisdom Publications.
Bowen, S., Chawla, N., Collins, S., Witkiewitz, K., Hsu, S., Grow, J., & Clifasefi, S. (2009).
Mindfulness-based relapse prevention for substance use disorders: A pilot efficacy trial.
Substance Abuse, 30, 295-305.
Bowen, S., Witkiewitz, K., Dillworth, T. M., Chawla, N., Simpson, T. L., Ostafin, B. D., …
Marlatt, G. A. (2006). Mindfulness meditation and substance use in an incarcerated
population. Psychology of Addictive Behaviours, 20, 243-347.
Bowen, S., Witkiewitz, K., Dillworth, T. M., & Marlatt, G. A. (2007). The role of thought
suppression in the relation between mindfulness meditation and alcohol use. Addictive
Behaviours, 32, 2324-2328.
Brown, K. W., Ryan, R. M., & Creswell, J. D. (2007). Mindfulness: Theoretical foundations
and evidence for its salutary effects. Psychological Inquiry, 18, 211-237.
Buddharakkhita (Trans.). (1966). Dhammapada: A Practical Guide to Right Living.
Bangalore: Maha Bodhi Society.
38
Cahn, B. R., Delome, A., & Polich, J. (2010). Occipital gamma activation during Vipassana
meditation. Cognitive Processing, 11, 39-56.
Carson, J. W., Keefe, F. J., Lynch, T. R., Carson, K. M., Goli, V., Fras, A. M., & Thorp, S. R.
(2005). Loving-kindness meditation for chronic low back pain: Results from a pilot trial.
Journal of Holistic Nursing, 23, 287–304.
Chah, A. (2011). The Collected Teachings of Ajahn Chah. Northumberland: Aruna
Publications.
Chan, W. S. (2008). Psychological attachment, no-self and Chan Buddhist mind therapy.
Contemporary Buddhism, 9, 253-264.
Chiesa, A. (2010). Vipassana meditation: Systematic review of current evidence. Journal of
Alternative and Complementary Medicine, 16, 37-46.
Chiesa, A. (2012). The difficulty of defining mindfulness: Current thought and critical issues.
Mindfulness, DOI:10.1007/s12671-012-0123-4.
Chiesa, A., Calati, R., & Serretti, A. (2011). Does mindfulness training improve cognitive
abilities? A systematic review of neuropsychological findings. Clinical Psychology
Review, 31, 449-464.
Chiesa, A., & Serretti, A. (2011). Mindfulness based cognitive therapy for psychiatric
disorders: A systematic review and meta-analysis. Psychiatry Research, 187, 441-453.
Chiesa A., & Malinowsko, P. (2011). Mindfulness-based approaches: Are they all the same?
Journal of Clinical Psychology, 67, 404-424.
39
Chodron, P. (1996). Awakening Loving Kindness. Boston: Shambala.
Crane, R. S., Kuyken, W., Williams, J. M., Hastings, R. P., Cooper, L., & Fennell, M. J.
(2012). Competence in teaching mindfulness-based courses: Concepts, development and
assessment. Mindfulness, 3, 76-84.
Crane, R. S., Eames, C., Kuyken, W., Hastings, R. P., Williams, J. M. G, Bartley, T., …
Surawy, C. (2013). Development and validation of the Mindfulness-Based Interventions –
Teaching Assessment Criteria (MBI:TAC). Assessment, DOI:
10.1177/1073191113490790.
Cristopher, M. S. (2003). Albert Ellis and the Buddha: Rational soul mates? A comparison of
Rational Emotive Behavior Therapy (REBT) and Zen Buddhism. Mental Health, Religion
& Culture, 6, 283-293.
Curry, O. S., Price, M. E., & Price, J. G. (2008). Patience is a virtue: Cooperative people have
lower discount rates. Personality and Individual Differences, 44, 780-785.
Dalai Lama. (1995). Essential Teachings. London: Souvenir Press.
Dalai Lama. (1995). The Path to Enlightenment. New York: Snow Lion.
Dalai Lama. (2000). Ancient Wisdom, Modern World: Ethics for the New Millennium.
London: Abacus.
Dalai Lama. (2001). Stages of Meditation: Training the Mind for Wisdom. London: Rider.
Dalai Lama. (2004). Dzogchen: Heart Essence of the Great Perfection. New York: Snow
Lion.
40
Dalai Lama. (2005). The Many Ways to Nirvana. London: Mobius.
Dalai Lama, & Berzin, A. (1997). The Gelug/Kagyu Tradition of Mahamudra. New York:
Snow Lion Publications.
Desbordes, G., Negi, L. T., Pace, T. W. W., Wallace, B. A., Raison, C. L., & Schwartz, E. L.
(2012). Effects of mindful-attention and compassion meditation training on amygdala
response to emotional stimuli in an ordinary, non-meditative state. Frontiers in Human
Neuroscience. 6, 292.
de Vibe, M., Bjørndal, A., Tipton, E., Hammerstrøm, K. T., & Kowalski, K. (2012).
Mindfulness based stress reduction (MBSR) for improving health, quality of life, and
social functioning in adults. The Campbell Collaboration, 3, DOI: 10.4073/csr.2012.3.
Dorjee, D. (2010). Kinds and dimensions of mindfulness: Why it is important to distinguish
them. Mindfulness, 1, 152-160.
Dudjom, K. (2005). Wisdom Nectar. Dudjom Rinpoche's Heart Advice. New York: Snow
Lion Publications.
Duncan, L. G., & Bardacke, N. (2010). Mindfulness-based childbirth and parenting
education: Promoting family mindfulness during the perinatal period. Journal of Child and
Family Studies, 19, 190-202.
Eberth, J. & Sedlmeier, P. (2012). The effects of mindfulness meditation: A meta-analysis.
Mindfulness, 3, 174–189.
41
Ekman, P., Davidson, R. J., Ricard, M., & Wallace A. B. (2005). Buddhist and psychological
perspectives on emotions and well-being. Current Directions in Psychological Science,
14, 59-64.
Elias, M. (2009). Mindfulness meditation being used in hospitals and schools. USA Today.
Accessed 5th February 2013. http://usatoday30.usatoday.com/news/health/2009-06-07-
meditate_N.htm
Fjorback, L. O., Arendt, M., Ørnbøl, E., Fink, P., & Walach, H. (2011). Mindfulness-based
stress reduction and mindfulness-based cognitive therapy - a systematic review of
randomized controlled trials. Acta Psychiatrica Scandinavica, 124, 102-119.
Follette, V., Palm, K. M., & Pearson, A. N. (2006). Mindfulness and trauma: Implications for
treatment. Journal of Rational-Emotive & Cognitive-Behaviour Therapy, 24, 45-61.
Gethin, R. (2011). On some definitions of mindfulness. Contemporary Buddhism, 12, 263-
279.
Gilbert, P. (2009). Introducing compassion-focused therapy. Advances in Psychiatric
Treatment, 15, 199-208.
Gilbert, P., & Procter, S. (2006). Compassionate mind training for people with high shame
and self-criticism: Overview and pilot study of a group therapy approach. Clinical
Psychology & Psychotherapy, 13, 353–379.
Gillani, N. B., & Smith, J. C. (2001). Zen meditation and ABC relaxation theory: An
exploration of relaxation states, beliefs, dispositions, and motivations. Journal of Clinical
Psychology, 57, 838-846.
42
Grossman, P., Niemann, L., Schmidt, S., & Walach, H. (2004). Mindfulness-based stress
reduction and health benefits: A meta-analysis. Journal of Psychosomatic Research, 57,
35-43.
Hall, G. C. N., Hong, J. J., Zane, N. W. S., & Meyer, O. L. (2011). Culturally competent
treatments for Asian Americans: The relevance of mindfulness and acceptance-based
psychotherapies, Clinical Psychology: Science and Practice, 3, 215-231.
Har, D. (1999). The Bodhisattva Doctrine in the Buddhist Sanskrit Literature. Delhi: Motilal
Banarsidass.
Hayes, S., Strosahl, K., & Wilson, K. (1999). Acceptance and Commitment Therapy. New
York: Guildford Press.
Hodgins, D. C., Currie, S. R., el-Guebaly, N., & Diskin, K. (2007). Does providing extended
relapse prevention bibliotherapy to problem gamblers improve outcome. Journal of
Gambling Studies, 23, 41-54.
Hofmann, S. G., Grossman, P., & Hinton, D. E. (2011). Loving kindness and compassion
meditation: Potential for psychological interventions. Clinical Psychology Review, 31,
1126-1132.
Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-
based therapy on anxiety and depression: A meta-analytic review. Journal of Consulting
and Clinical Psychology, 78, 169-183.
Howells, K., Tennant, A., Day, A., & Elmer, R. (2010). Mindfulness in forensic mental
health: Does it have a role? Mindfulness, 1, 4-9.
43
Huang Po. (1982). The Zen Teaching of Huang Po: On the Transmission of the Mind.
(Blofeld, J., Trans.) New York: Grove Press.
Jacobs, S. (1993). Pathological Grief: Maladaption to Loss. Washington, DC: American
Psychiatric Press.
Johnson, D. P., Penn, D. L., Fredrickson, B. L., Kring, A. M., Meyer, P. S., Catalino, L. I., &
Brantley, M. (2011). A pilot study of loving-kindness meditation for the negative
symptoms of schizophrenia. Schizophrenia Research, 129, 137-140.
Johnson, D. P., Penn, D. L., Fredrickson, B. L., Meyer, P. S., Kring, A. M., & Brantley, M.
(2009). Loving kindness to enhance recovery from negative symptoms of schizophrenia.
Journal of Clinical Psychology, 65, 499-509.
Kabat-Zinn, J. (1990). Full Catastrophe Living: Using the wisdom of your body and mind to
face stress, pain and illness. New York: Delacourt.
Kabat-Zinn, J. (1994). Wherever you go, there you are: Mindfulness Meditation in Everyday
Life. New York: Hyperion.
Kang, C., & Whittingham, K. (2010). Mindfulness: A dialogue between Buddhism and
clinical psychology. Mindfulness, 1, 161-173.
Kelly, B. D. (2008). Buddhist psychology, psychotherapy and the brain: A critical
introduction. Transcultural Psychiatry, 45, 5-30.
Khyentse, D. (2007). The Heart of Compassion: The Thirty-seven Verses on the Practice of a
Bodhisattva. Boston: Shambhala Publications.
44
Klainin-Yobas, P., Cho, M.A.A., & Creedy, D. (2012). Efficacy of mindfulness-based
interventions on depressive symptoms among people with mental disorders: A meta-
analysis. International Journal of Nursing Studies, 49, 109-121.
Kongtrul, J. (1992). Cloudless Sky: The Mahamudra Path of the Tibetan Buddhist Kagyu
School. (R. Gravel, Trans.) London: Shambhala Punblications Inc.
Kristeller, J. L., & Wolever, R. D. (2011). Mindfulness-based eating awareness training for
treating binge eating disorder. Eating Disorders, 19, 49-61.
Kumar, S. M. (2005). Grieving Mindfully: A Compassionate and Spiritual Guide to Coping
with Loss. Oakland, CA: New Harbinger.
K'uan Yu, L. (1976). Ch'an and Zen Teaching. London: Rider and Company.
Ledesma. D, & Kumano, H. (2009). Mindfulness-based stress reduction and cancer: A meta-
analysis. Psycho-Oncology, 18, 571-579.
Lindberg, D. (2005). Integrative review of research related to meditation, spirituality, and the
elderley. Geriatric Nursing, 26, 327-277.
Linehan, M. (1993). Cognitive Behavioral Treatment of Borderline Personality Disorder.
New York: Guildford Press.
Mascaro, J. S., Rilling, J. K., Negi, L. T., & Raison, C. L. (2012). Compassion meditation
enhances empathic accuracy and related neural activity. Social Cognitive and Affective
Neuroscience, DOI:10.1093/scan/nss095.
45
Mayhew, S. L., & Gilbert, P. (2008). Compassionate mind training with people who hear
malevolent voices: A case series report. Clinical Psychology & Psychotherapy, 15, 113-
136.
McWilliams, S. A. (2011). Contemplating a contemporary constructivist Buddhist
psychology. Journal of Constructivist Psychology, 24, 268-276.
Mental Health Foundation. (2010). Mindfulness Report. London: Author.
Michalon, M. (2001). "Selflessness" in the service of the ego: Contributions, limitations and
dangers of Buddhist psychology for Western psychotherapy. American Journal of
Psychotherapy, 55, 202-218.
Nhat Hanh, T. (1992). The Sun My Heart. London: Rider.
Nhat Hanh, T. (1999). The Heart of the Buddha's Teaching: Transforming Suffering into
Peace, Joy and Liberation. New York: Broadway Books.
Nhat Hanh, T. (1999). Call Me By My True Names. Berkeley: Parallax Press.
Nanamoli Bhikkhu. (1979). The Path of Purification: Visuddhi Magga. Kandy (Sri Lanka):
Buddhist Publication Society.
Nyanaponika Thera. (1983). The Heart of Buddhist Meditation. London: Rider.
National Institute for Health and Clinical Excellence (NICE). (2009). Depression:
Management of Depression in Primary and Secondary Care. London: Author.
Norbu, C. & Clemente, A. (1999). The Supreme Source. The Fundamental Tantra of the
Dzogchen Semde. New York: Snow Lion Publications.
46
Pace, W. W., Negi, L. T., Adame, D. D., Cole, S. P., Sivilli, T. I., Brown, T. D., … Raison,
C. L. (2009). Effect of compassion meditation on neuroendocrine, innate immune and
behavioral responses to psychosocial stress. Psychoneuroendocrinology, 34, 87-98.
Pace, T., Negi, L., Dodson-Lavelle, B., Ozawa-de Silva, B., Reddy, S., Cole, S., … Raison,
C. L. (2012). Engagement with Cognitively-Based Compassion Training is associated with
reduced salivary C-reactive protein from before to after training in foster care program
adolescents. Psychoneuroendocrinology, DOI: 10.1016/j.psyneuen.2012.05.019.
Perelman, A. M., Miller, S. L., Clements, C. B., Rodriguez, A., Allen, K., & Cavanaugh, R.
(2012). Meditation in a deep south prison: A longitudinal study of the effects of vipassana.
Journal of Offender Rehabilitation, 51, 176-198.
Ponlop, D. (2003). Wild Awakening. The Heart of Mahamudra & Dzogchen. Boston:
Shambhala.
Rabjam, L. (2002). The Practice of Dzogchen. (H. Talbot, Ed., & Tulku Thondup, Trans.)
New York: Snow Lion Publications.
Reat, N. R. (1993). The Shalistamba Sutra. Dehli: Molital Baranasidas.
Reddy, S. D., Negi, L. T., Dodson-Lavelle, B., Ozawa-de Silva, B., Pace, T.W., Cole,
S.P., … Craighead, L. W. (2012). Cognitive-Based Compassion Training: A promising
prevention strategy for at-risk adolescents. Journal of Child and Family Studies, DOI
10.1007/s10826-012-9571-7.
Rhys Davids, T. W., (1881). Buddhist Suttas. Oxford: Clarendon Press.
47
Rosch, E. (2007). More than mindfulness: when you have a tiger by the tail, let it eat you.
Psychological Inquiry, 18, 258-264.
Rungreangkulkij, S., Wongtakee, W., & Thongyot, S. (2011). Buddhist Group Therapy for
diabetes patients with depressive symptoms. Archives of Psychiatric Nursing, 25, 195-205.
Sahdra, B. K., Shaver, P. R., & Brown, K. W. (2010). A scale to measure non-attachment: A
Buddhist complement to Western research on attachment and adaptive functioning.
Journal of Personality Assessment, 92, 116-127.
Sampson, E. E. (1999). Dealing with Differences: An Introduction to the Social Psychology
of Prejudice. New York: Harcourt Brace College Publishers.
Santideva. (1997). A Guide to the Bodhisattva Way of Life. (V. A. Wallace, & A. B. Wallace,
Trans.) New York: Snow Lion Publications.
Sedikides, C. & Spencer, S. J. (Eds.). (2007). The Self. New York: Psychology Press.
Segal, Z. V., Williams, J. M., & Teasdale, J. D. (2002). Mindfulness-based Cognitive
Therapy for Depression: A New Approach to Preventing Relapse. New York: Guilford.
Segall, S. R. (2003). Psychotherapy practice as Buddhist practice. In S. R. Segall (Ed.),
Encountering Buddhism: Western Psychology and Buddhist Teachings (pp. 165-178).
New York: State University of New York Press.
Shonin, E., Van Gordon W., & Griffiths M. D. (2013a). Meditation Awareness Training
(MAT) for improved psychological wellbeing: A qualitative examination of participant
experiences. Journal of Religion and Health, DOI: 10.1007/s10943-013-9679-0.
48
Shonin, E., Van Gordon W., & Griffiths M. D. (2013b). Buddhist philosophy for the
treatment of problem gambling. Journal of Behavioural Addictions, 2, 63-71.
Shonin, E., Van Gordon W., Slade, K., & Griffiths M. D. (2013c). Mindfulness and other
Buddhist-derived interventions in correctional settings: A systematic review. Aggression
and Violent Behaviour, 18, 365-372.
Shonin, E., Van Gordon, W., & Griffiths, M. D. (2013d). Mindfulness-based interventions:
Towards mindful clinical integration. Frontiers in Psychology, 4, 194, DOI:
10.3389/fpsyg.2013.00194.
Sills, M., & Lown, J. (2008). The field of subliminal mind and the nature of being. European
Journal of Psychotherapy and Counselling, 10, 71-80.
Singh, N. N., Lancioni, G. E., Wahler, R. G., Winton, A. S., & Singh, J. (2008). Mindfulness
approaches in cognitive behavior therapy. Behavioral and Cognitive Psychotherapy, 36, 1-
8.
Smith, J. C. (1999). ABC Relaxation Theory: An Evidence-based Approach. New York:
Springer.
Soeng, M. (1995). Heart Sutra: Ancient Buddhist Wisdom in the Light of Quantum Reality.
Cumberland: Primary Point Press.
49
Soler, J., Valdepérez, A., Feliu-soler, A. Pascual, J., Portella, M., & Martín-blanco, A., …
Perez, V. (2012). Effects of the dialectical behavioral therapy-mindfulness module on
attention in patients with borderline personality disorder. Behaviour Research and
Therapy, 50, 150-157.
Sogyal Rinpoche. (1998). The Tibetan Book of Living and Dying. London: Rider.
Suzuki, D. T. (1983). Manual of Zen Buddhism. London: Rider.
Teasdale, J. D., Segal, Z. V., & Williams, J. M. G. (1995). How does cognitive therapy
prevent depressive relapse and why should attention control mindfulness training help?
Behavior Research and Therapy, 33, 25-39.
Thompson, B. L., & Waltz, J. (2008). Self-compassion and PTSD symptom severity. Journal
of Traumatic Stress, 21, 556-558.
Toneatto, T., & Nguyen, I. (2007). Does mindfulness meditation improve anxiety and mood
symptoms? A review of the controlled research. La Revue Canadienne di Psychiatrie, 52,
260-266.
Trungpa, C. (2002). Cutting Through Spiritual Materialism. Boston: Shambala.
Trungpa, C. (2003). The Collected Works of Chogyam Trungpa: Volume Four. Boston:
Shambala.
Trungpa, C. (2006). The fourth moment. Shambala Sun, 14, 44-45.
Tsong-Kha-pa. (2004). The Great Treatise on the Stages of the Path to Enlightenment (Vol.
1). (J. W. Cutler, G. Newland, Eds., & The Lamrim Chenmo Translation committee,
Trans.) New York: Snow Lion Publications.
50
Urgyen, T. (2000). As It Is. (M. B. Schmidt, K. Moran, Eds., & E. Pema Kunsang, Trans.)
Hong Kong: Rangjung Yeshe Publications.
Van Gordon, W., Shonin, E., Sumich, A., Sundin, E., & Griffiths, M. D. (2013). Meditation
Awareness Training (MAT) for psychological wellbeing in a sub-clinical sample of
university students: A controlled pilot study. Mindfulness, DOI: 10.1007/s12671-012-
0191-5.
Vøllestad, J., Nielsen, M. B., & Nielsen, G. H. (2012). Mindfulness and acceptance-based
interventions for anxiety disorders: a systematic review and meta-analysis. British Journal
of Clinical Psychology, 51, 239-60.
Wada, K., & Park, J. (2009). Integrating Buddhist psychology into grief counseling. Death
Studies, 33, 657-683.
Walshe, M. (Trans.) (1995). The Long Discourses of the Buddha: A Translation of the Digha
Nikaya. Boston: Wisdom Publications.
Witkiewitz, K., Bowen, S., Douglas, H. & Hsu, S. (2013). Mindfulness-based relapse
prevention for substance craving. Addictive Behaviors, 38, 1563-1571.
Yoder, E. A. (2010). Compassion fatigue in nurses. Applied Nursing Research, 23, 191-197.
Zadra, A., & Donderi, D. C. (2000). Nightmares and bad dreams: their prevalence and
relationship to well-being. Journal of Abnormal Psychology, 109, 273-281.
Table 1 Questions pertinent to the effective operationalization of mindfulness in clinical and
psychological domains
51
Facet of Mindfulness
Meditation
Illustrative Question
Connectivity to other
meditative
components
Is mindfulness (e.g., as utilized in programs such as MBSR and
MBCT) considered to be a standalone practice or just one key
faculty of meditation that cooperates with properties such as
‘concentration’ and ‘vigilance’?
Attentional breadth Does use of the term ‘mindfulness meditation’ (i.e., in Western
psychological contexts) simply refer to the practice of everyday
mindfulness (as practiced during day-to-day tasks) while
adopting a seated meditation posture?
Conversely, does seated mindfulness meditation involve greater
concentration on a particular object of mind (such as the breath,
feelings, or thoughts)?
If so, in what way does mindfulness meditation differ from
referential forms of concentrative (samatha) meditation?
If seated mindfulness meditation practice does not involve such
object-focussed concentration, then in what way does it differ
from non-referential open-aspect forms of samatha meditation in
which present moment experience is assumed as the focus of
concentration?
Insight generation Do qualities of mindfulness meditation such as “a clear focus on
aspects of active investigation of moment-to-moment experience”
(Hofmann et al., 2011, p.1127) refer to a more analytical (and
therefore insight-generating) component?
If so, is this an active form of analysis (consistent with the
traditional Buddhist approach – see Chah, 2011; Dalai Lama &
Berzin, 1997) that refers to a distinct shift towards a more
penetrative meditative mode (i.e., by searching for ‘the self’, ‘the
mind’, or the intrinsic existence of a particular object)?
Alternatively, does the Western clinical operationalization of
mindfulness meditation feature a more passive form of analysis
(as appears to be the case in S.N. Goenka’s VM approach) in
which (for example) ‘insight’ simply refers to a better
understanding of “the nature of thoughts and feelings as passing
events in the mind” (Bishop et al., 2004, p.234)?
52
i Although a number of prominent Buddhist scholars and teachers (e.g., the Dalai Lama) support the use of the
term ‘Shravakayana for referring to the first Buddhist ‘yana’, others view this as inadequate because
Shravakayana appears to be terminology primarily employed by Mahayana/Vajrayana approaches. Likewise,
Shravakyana does not by default encompass the mode of practice of the ‘pratyeabuddha’ – a practice mode
generally attributed to the first Buddhist ‘yana’. An alternative to ‘Shravakayana’ is the term ‘Hinayana’.
However, ‘Hinayana’ is pejorative vernacular as it means ‘lesser vehicle’. Simply referring to the first vehicle as
‘Theravada’ is equally problematic because the term Theravada refers to only one of the original 18 Buddhist
schools commonly associated with the first transmission cycle of the Buddhist teachings. Thus, there is (a
longstanding) debate within Buddhism regarding the most apt term for referring to the first Buddhist vehicle.
ii While Theravada is the longest-surviving Buddhist tradition and is the modern day descendant of the historical
Sthaviravada Buddhist school, it should be distinguished from pre-sectarian Buddhism that survived for
approximately 100 to 150 years after the death of the Buddha. iii Although many Buddhist teachers advocate a gradual approach to the development of wisdom, other teachers
(e.g., in certain Zen traditions) subscribe to an ‘instant’ view of enlightenment. However, Trungpa (2006)
contends that even where wisdom (or enlightenment) manifests ‘instantly’, such a breakthrough of realization
simply reflects the coming to fruition of practice-born insights that had hitherto remained latent.
iv In certain Buddhist systems a fourth seal of ‘Nirvana’ is included.
v Serenity and insight techniques are integral to the development of meditative awareness and are practiced by
the vast majority of Buddhist traditions (including traditions from each of the three Buddhist vehicles).
However, there are a number of exceptions to this generalization especially in certain Zen Buddhist traditions.
vi As with many Buddhist practices, vipassana meditation is operationalized differently by different Buddhist
traditions. Nevertheless, there is a strong degree of concordance between the three Buddhist vehicles that
vipassana meditation involves the use of penetration analysis as a means generating meditative insight or
wisdom. For example, In traditional Theravada vipassana practice, the practitioner learns to see the aggregate
(or skandha-nature) of all phenomena. Instead of seeing things as substances with an essential core, the
meditator trains to see phenomena as composed of ‘skandha parts’. All things granulate - no permanent core
remains. When the practitioner can see the world through this granulating lens, then insight is said to have
arisen. In Mahayana contexts, insight and therefore vipassana practice is depicted in a similar manner but relates
more to realizing a ‘non-dual’ outlook – the disintegration of the self-other divide: “I am the child in Uganda,
all skin and bones, my legs as thin as bamboo sticks, and I am the arms merchant, selling deadly weapons to
Uganda” (Nhat Hanh, 1999, p.72,).
vii Techniques such as Transcendental meditation, kundalini yoga, sahaja yoga, and hatha yoga are not explicitly
Buddhist-based (i.e., they derive from Hinduism) and are therefore not discussed in the current paper.
viii Other interpretations of ‘sukha’ typically depict it as a ‘blissful’ state – particularly in association with
Theravada jhana practice.